Purpose :
Retrospective chart review examining the efficacy of punctal cautery on the symptoms and signs of chronic ocular GVHD.

Methods :
23 patients with ocular GVHD who received punctal cautery by a single ophthalmologist listed on a surgical log between January 1, 2014 and November 1, 2017 were evaluated before and after treatment. OSDI, Schirmer’s testing, and corneal staining data were extracted retrospectively. Paired t-tests of mean pre- and post-OSDI scores were calculated.

Results :
70% of patients were female with a mean age of 56 years (range 33-77). The mean time between stem cell transplant (SCT) and punctal cautery was 27 months (range 5-68). Mean Schirmer’s without anesthesia (5 minutes) pre-treatment was very low at 5.82 for OD and 3.35 for OS (range 0-52 and 0-35, respectively). The mean OSDI post-treatment was 35.4 (range 0-86.1), which was statistically significantly improved from the pre-treatment mean OSDI of 52.7 (range 13.6-91.7) (p=0.0029). Four of the total 23 patients had removal of prior placed lower lid silicone punctal plugs at the time of punctal cauterization. 35% of OD and 48% of OS corneas had improved fluorescein staining by the next slit lamp exam 1-4 weeks later.

Conclusions :
Ocular GVHD patients with severe dry eye symptoms are often a challenge to care for. Schirmer’s testing without anesthesia, though cumbersome and lengthy to perform, often confirms that patients have severe aqueous deficiency. Though Schirmer’s testing is no longer required for NIH GVHD staging, it is useful for guiding treatment options. Though the graft-versus-host response needs to be controlled to limit further destruction of lacrimal, meibomian, and mucin production, patients significantly benefit from treatment of aqueous deficiency. Autologous serum tears are limited in economic availability and are difficult to obtain and store. Punctal cautery must be used cautiously in less severe dry eye disorders, but these severe globally dry ocular GVHD patients with low reflex tearing capacity are not at risk for epiphora. Punctal plugs can be used in the short-term. But in the long-term, silicone plugs tend to fall out, rub the bulbar conjunctiva in patients with entropic punctal position, or eventually develop a biofilm that likely affects the ocular microbiome. Prospective studies of punctal plugs versus punctal cautery are needed to establish each type of punctal occlusion’s utility in an algorithm for treating chronic ocular GVHD.

This is an abstract that was submitted for the 2018 ARVO Annual Meeting, held in Honolulu, Hawaii, April 29 - May 3, 2018.